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Introduction
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There is no mental disorder that is inevitable in old age. Most older people describe their overall well-being as good. Hence there is such a thing as "normal" ageing in terms of mental (as well as physical) health. Nevertheless, as in all age groups, mental disorder is not uncommon in older people and there are some disorders that become more prevalent as age increases. Mental disorder in old age can be divided into two broad categories:
- Organic disorders
These are characterized by confusion, which may be acute (i.e. delirium) or chronic (i.e. dementia); - Functional disorders
Such as depression, anxiety and panic; but also psychotic disorders, such as late-onset schizophrenia (formerly known as "late paraphrenia").
In addition, drug and alcohol misuse and dependence can (like many disorders) continue into old age, or emerge for the first time when the person is older. Similarly, it should not be forgotten that personality difficulties do not necessarily disappear with ageing.
Epidemiology
The prevalence of mental disorder in elderly people depends on exactly which age group is examined and where they are living. In community surveys of all people aged over 65 years, approximately 5% are found to have severe organic brain disorders (mainly dementia) and a further 5% to have mild symptoms of forgetfulness. 2.5-5% will have depression severe enough to warrant treatment with a further 10% complaining of minor depressive/anxiety symptoms. Late onset schizophrenic illnesses are much less common, perhaps 0.5-1.0%.
If one looks at the very elderly (greater than 80 years) the rates of organic disorders, mainly dementia, are much increased, (e.g. 20%) whereas other diagnoses may occur less frequently - in other words organic disorder is (as one might expect) a disorder associated with increasing age.
In residents in local authority homes, hospitals or other institutional care, the rates for both organic and functional disorder (particularly depression) are much increased - about 30% for each type. It is probable that mental disorder will have contributed to the person entering the institution, e.g. dementia making them unable to survive safely in their own home - but the combination of losing one's home and familiar surroundings can also aggravate existing confusion and/or depression.
Ethics and Law
The main ethical concern in older people relates to the issue of capacity. In some jurisdictions (e.g. Scotland) there are now laws around incapacity. Capacity legislation will appear shortly in England and Wales. Irrespective of the legislation, however, the need to maintain the older person's ability to make autonomous decisions is clearly of ethical importance. Autonomy can be undermined by both professionals and families for both benign and malignant reasons. The presumption should always be that the person has the capacity to make a particular decision. Judgements about capacity should always be made with respect to a specific ability: a person may not be able to drive, but may still be able to run his or her own finances. Having a particular capacity (or competence) means that the person can recall and understand the relevant information and that the person shows evidence of weighing up the information as he or she makes a decision (which need not be the decision that the person assessing capacity would have reached).
If the person lacks capacity, those involved must act in the person's best interests. These have to be understood broadly. The criteria for assessing a person's best interests should include: taking account of what the person has said or stipulated (e.g. on an advance directive or "living will") in the past; taking account of what the person now says when enabled to participate in the decision; taking account of the views of all those other people involved in the person's welfare, insofar as this is practicable, especially as regards what they think the person's wishes would have been under the present circumstances if the person had been able to express his or her wishes; making sure that the least restrictive course of action is taken.
There are particular procedures to be followed if the person lacks certain capacities. For instance, there is a variety of steps to be taken (involving the Court of Protection) when the person cannot manage his or her finances; and if the person lacks the capacity to drive, the requirements of confidentiality may be put aside in the interests of public safety. Having said this, however, the doctor's duty is to be on the side of the patient and it is an affront to the person's standing as an autonomous individual if his or her abilities are undermined without due cause. The General Medical Council offers advice on such issues.
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